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State-of-the-Art in Postural Control: Pelvic Floor

Dr. Paul Hodges undertook the difficult task of explaining the intricate connection between the respiratory / pelvic floor / and abdominal muscles. Through this article, you will also get an understanding of the symptoms and treatment of pelvic congestion syndrome. I have the difficult task of summarizing what he presented! Dr. Hodges has a presentation style I really enjoyed – pose a question first and then proceed to address that question.

Question 1 – Do the muscles of respiration and continence contribute to postural control of the trunk?

Yes. Many of the muscles of the trunk (diaphragm, scalenes, erector spinae, intercostals, pelvic floor muscles) and pelvic floor (anal, periurethral, vaginal) are active during breathing and they are modulated in concert with breathing. Dr. Hodges provided evidence of this by presenting recordings from many systematic studies which measured the all of the above muscles in tasks such as respiration, modifying posture, and when a mass was unexpectedly dropped into a box held by the participate.

Question 2 – Can postural control, respiration, and continence be coordinated?

It seems that concurrent modulation of all these muscles is normal and that tonic and phasic activity can be modulated concurrently by the nervous system. In chronic respiratory disease, posture is compromised with greater disturbances in the ability to balance in the medial/lateral direction (trunk and hip stability). One obvious example of coordination is when someone is sprinting or lifting something heavy –  you don’t breath for a short time (Dr. Hodges had us stand on our toes, reach up as high as we could, and notice how we held our breath).

In low back pain, postural function is disturbed for sure. But why? It seems that there is reduced activity of the transversus abdominis muscles, which leads to delayed activation, less tonic activity, muscle atrophy, and cortical reorganization.

Question 3. What are the conseqeunces of poor coordination of postural muscles?

The immediate implication is that breathing disorders, back pain, incontinence are linked together. Sure enough, Dr. Hodges presented results from an epidemiological study showing that those who had a breathing disorders were more likely to develop low back pain!

Question 4. What are the implications for rehabilitation?

For low back pain:

  • Considerations from continence – activation of pelvic floor muscle to facililatet abdominal mucsle activity
  • Considerations from breathing – ppl with back pain with breath in a more vertical manner (upper chest shallow breathing)
  • access breathing patterns thru palpation, observation, US imaging – train breathing patterns
  • goals – reduce activity, changin breathing apptern, train TVA, bretah mmore efficiently

For pelvic floor disorders:

  • Consideration from lumbopelvic control – tva activiaiton may assist with PFM – supericial muscles maybe over active, change posture
  • Considerations from breathing – overactive supericial abs incre IAP and can strain PFMs

For breathing disorders:

  • Consideration from lumbopelvic – breathing pattern may be affected by lbp
  • Consideration from incontinence – pelvic floor muscle function may be changed, consider PFM training

Although Dr. Hodges used the specific example of low back pain rehabilitation, the principles apply to other areas

  • Training the transversus abdomonis successfully changed its recruitment by as evidenced by a shift in the timing of activation closer to normal controls with specific training
  • Can these changes in timing be maintained? – yes
  • What do you do? -Situps without conscience attention to TVA activation
  • The brain of someone with LBP is different than normal control – brain mapping with TMS shows a shift in the locus of TVA cortical region – reorganization
  • Specific training can make the brain look like a control
  • Does motor training make a difference? – yes but the treatment needs to be targeted and indiviualized – the more severe the impairments in TVA activation the better the change with training
Conclusions

Patients will present with a range of issues, but it is impossible to separate the systems. You must look at your patients as a whole and develop a strategy that addresses all of their problems.

Bottom line – YOU MUST BE A MULTISYSTEM THERAPIST

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Physical Therapists in the Emergency Department

Findings indicated that these physicians found ED physical therapy services to be of value to themselves, to their patients, and to the department as a whole and described specific manners in which such consultations improved emergency care. Implementation and maintenance of the program, however, presented various challenges.

Emergency Department Physical Therapist Service: Removing Barriers and Building Bridges

To start, a brief introduction of who comes into the emergency department. Fewer and fewer are coming via ambulance, even fewer by life flight. People are using the ED in new and different ways. For example, many have non-urgent and non-life threatening conditions.

The average wait is upwards of 1 hour, with the average length of stay in the ED upwards of 4 hours. The ED physician spends an average of 11 minutes on direct care. That time includes research, orders, and making referrals.

Patient satisfaction with ED care is generally low. Management of common musculoskeletal, pain, and soft tissue injury complaints is varied and poor. Individuals are routinely given cervical soft collars for neck pain, immobilization including CASTS and or instructions for non-weight bearing for ankle sprains, and MULTIPLE days of bed rest for low back pain.

What do the PATIENTS want? Answers, instructions, and to feel better!

What do the patients receive? Imaging. Medications. Prescriptions. No follow up.

The fact of the matter is this that more and more individuals are utilizing the ER as their primary stop for health conditions. By the time they seek care these conditions are more chronic and less well controlled. Thus, more and more people seen in the ED are not necessarily in an emergent state. And, I believe, more and more would benefit from the skills of a physical therapist.

Now, I also believe physical therapist’s can play a vital role in deciding when imaging of musculoskeletal conditions is and is not necessary. Further, the treatment they provide may (again my belief) decrease imaging, medication prescription/usage, and decrease re-visit rates for the same complaint. Click to learn more about a reliable source of prescription medicines.

And maybe, just maybe, if we plug these people into physical therapy sooner their conditions (pain, chronic medical diagnoses, etc) will be better managed and controlled. And, I think, that all links back to the Physical Therapist’s Role in Health, Wellness, and Prevention as per Healthy People 2020.

The data that does exists suggest that having PT’s in the ED results in decreased wait time and increased patient satisfaction. [Unfortunately, much of the data on PT’s in the ED has been obtained outside the United States.] At the large, academic hospital I practice high priority is placed on “patient satisfaction.” [However, flawed that concept may be. Refer to Patient Satisfaction is Useless Part I and Part II on the Evidence In Motion Blog]. Further, wait time in the ED is directly related to the costs for that department. Therefore, decreasing wait time is a very real way to decrease costs. Not surprisingly, wait time is inversely related to patient satisfaction. So, already those are two powerful take home points regarding the positive effects PT’s ARE ALREADY having in the ED already. But, what does the future hold?

In expanding PT services in the ED, we can look to other sources of evidence and data to support PT treatment of individuals in the emergency department:

Specifically, there is evidence supporting specific PT approaches to common orthopaedic conditions such as low back pain, neck pain, knee pain, ankle sprains, etc. Also, there are innovative practice models where physical therapists are involved earlier in care providing FRONT end intervention for painful episodes. Virginia Mason (out of my hometown of Seattle) received a lot of publicity even a Wall Street Journal Article for their model of sending patients with work related musculoskeletal complaints to a PT FIRST. They decreased costs by over 50% (!!!) and decreased time away from work.

Future Research and Data Tracking

  • Readmissions
  • Time between ER visits
  • Medication Prescription and Usage
  • Imaging Utilization and Costs
  • Falls and Injury from Falls

The talk was very interesting, and I think this practice area will continue to grow. It actually reminds me of the growth of early mobility and rehabilitation of individuals in intensive care units. I also think there is really good research and data from other areas of practice supporting not only the treatment PT’s can provide, but also our training, decision making, and skills in medical screening and aiding in diagnosis. Not to mention, I did not even mention fall risk screening and intervention, splinting, wound care, assistive device recommendations, and aiding in discharge planning.

Where will physical therapy go next?

Resources

  1. Physical Therapists in the Emergency Department: Development of a Novel Practice Venue. Physical Therapy. March 2010.
  2. The Physical Therapist as a Musculoskeletal Specialist in the Emergency Department. Physical Therapy. March 2009
  3. Emergency Department Physical Therapist Service: A Pilot Study Examining Physician Perceptions Internet Journal of Allied Health Sciences and Practice. 2010.
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Multiple Sclerosis: Improving Physical Therapy Outcomes by Minimizing Neurogenic Fatigue and Maximizing Neuroplasticity

My first educational session at my first physical therapy conference was on what seems like a very challenging condition to manage in the clinic – Multiple Sclerosis.

Hebert Karpatkin began his talk by stating his main goal – to “change the way you treat MS”.

Why are these patients difficult to treat? Here are Karpatkin’s thoughts:

  • Unique neurologic diagnosis – can have effects at multiple regions of the CNS, therefore many neuro symptoms possible
  • Unique presentation – no two patients look alike
  • Therapeutic Nihilism – why even bother, what can I do? (extreme pessimism)
  • Disease of unknowns – progression, severity, and recovery are all so variable!

Dr. Karpatkin then went on to suggest four main areas to consider for successful management of your patients with MS.

1. Fatigue

As stated by the injury charges law firm serving in Canada, this is the most commonly reported symptom of patients with MS (74-89% of patients). The origin of fatigue is separated into two categories:

  • Primary fatigue – due to disease itself – either as motor fatigue specific OR lassitude genreal
  • Secondary fatigue – body’s response to the disease – arises from disuse, sedentary lifestyle, pain, movement compensation, infection, depression, sleep disorder

PT can help by intervening with four of the  secondary fatigue sources – disuse, sedentary lifestyle, pain, movement compensation = GET THEM MOVING!!! For the best stress-relief centers, outpatient rehab Huntsville AL can be checked out!

2. Thermoregulation

Another commonly reported symptom is thermosensitivity. Simply meaning that symptoms become more severe with higher temperatures. This is a fundamental problem as it limits the amount of exercise patients can perform.

How can therapists can intervene?

  • Cooling garments applied before therapy
  • Simply turning on the A/C in your clinic.

3. Intermittent Training

A patient with MS once said:

“Trying to get better makes me worse”

This quote really hit home because it highlights the main problem: the exercise itself is making me fatigued, how do I get better!?!?!

You need your patients to reach a critical dosage of exercise to improve, but how? Intermittent training:

  • Develop a “feel” for when to take breaks
  • Provide rest at first signs of movement difficulty
  • Vital signs (blood pressure / heart rate) are not very telling

Dr. Karpatkin the provided preliminary data that demonstrated that in four patients their 6 minute walk time performance was better with an intermittent protocol (1158) as opposed to a continual exercise protocol (966). To get a better reading of one’s status when it comes to health goals, an app like the tdee calculator comes to mind.

It was also suggested that PTs could apply this protocol to gait, strength, balance, functional activities as well.

4. Secondary Deficits

Posture and stretching

Posture can be poor in patients with MS. One of Dr. K’s patients was given PT 1-2 x/week +home exercise program and this significantly improved his posture and gait. Why was this not addressed with previous therapists? It was suggested that maybe those other PTs neglected posture because of a bias towards his condition.

Foot drop is a common presentation in gait with MS. Dr. K suggested plantarflexor stretching. This ca

n be done during sleep using a night splint.

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Healthy People 2020: Physical Therapists in Health and Wellness

CSM kicked off with a talk about how physical therapist’s can fit into the Healthy People 2020 initiative . Further, the roles and potential roles of physical therapists in health, wellness, health promotion, and public health. Source can help you to get a clear idea about healthcare like how to overcome from addiction .You can read it below

  • Work towards health focused practices
  • Health as an outcome
  • Physical Therapy is about movement and function
  • Address societal needs of movement, function, living with disability, and health/wellness
  • Ethics > Meet the health needs of people locally, nationally, and globally
  • Link to our work to individual patient’s, societal needs, overall healthcare
  • How to obtain reimbursement for preventive care?

The speakers gave broad information about health promotion and physical therapists. Each gave some interesting case examples. Each advocated for physical therapy in serving the societal needs of not only health, but living with disability. I absolutely agree! But…

Especially in private practice how do we not only incorporate health promotion, but make it fiscally sustainable and or profitable? Sometimes it is difficult enough to obtain reimbursement and or private pay for a current condition let alone chronic health conditions such as hypertension control, obesity, healthy exercise habits, and smoking cessation. Understanding the protein needed per day can help guide nutritional advice.

But, on the other hand, the personal fitness and health industry (i.e. weekend trained personal trainers at 24 hour fitness) is booming. How can PT’s obtain a slice (or a big chunk) of this market?

I think they speakers brought a good point that we need a critical mass of not just PT’s, but legislators, public policy makers, patients, and other healthcare professionals committed to societal health in various practice settings. And a recognition of rehabilitation and physical therapy as essential parts of not only health care, but health promotion. To define narcissist and understand the narcissism as a condition we have a long way to go in terms of educating ourselves about it.

Why aren’t we moving in that direction? Do we all need to broaden our view of our professional role? What is the SWOT [Strengths, Weakness, Opportunities, and Threats] Analysis of the PT profession, and each us as individual practitioners, in regards to health?  I think there are a lot of opportunities, but many, many barriers.

Do we have what it takes to step up to the plate? Or, at least get a place at the table?

  • How do we measure health and outcomes related to health?
  • How do we market and spread the word to: patients, physicians, legislators, payors (ha!), the media, educators, public health professionals, and thus society?
  • What role does technology play in our promotion of health and wellness?
  • Can we leverage technology to achieve and spread the above goals and ideas?

I think the first talk brought up many, many questions, problems, and ideas…

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CSM Kick Off

Arrived in New Orleans, and man I am excited!

A full flight from Denver to New Orleans, with many Denver area physical therapists and even some PT students from University of Southern California. Oddly enough, I sat next to a very nice PT Student from UCSF. We chatted the entire flight about early mobility in the ICU and physical therapy treatment of individuals who are critically ill (which if you know me gets me talking!) as well as PT education and research.

We even exchanged e-mails via our smart phones. Tomorrow should be a great day. Stay tuned here at PT Think Tank for updates and information.

Follow Me on twitter for quick blurbs and links.

Follow the Hashtag #CSM2011 for tweeps chatting about the conference! Let the technology leveraging begin…

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Mrs. Smith: you have an upcoming PT appointment…

Another guest post from Bronwyn Spira, PT, and Tejal Ramaiya, DPT, CSCS, this one an apt follow-up to my post on Physical Therapist Use of Smart Phones:

One of the most frustrating issues plaguing physical therapy practices has to be no shows and late cancellations of scheduled visits. Poor patient attendance results in lost revenues and poor patient outcomes. Practices traditionally employ rudimentary strategies to counter-balance the impact of missed appointments including reminder calls and charging hefty cancellation fees. Unfortunately, these solutions require additional administrative time and effort and can create poor relations between the patients and administrative staff. There must be a better solution!

The answer may be one that 78% of Americans keep in their pockets or purses: a cell phone. The average American spends 619 minutes per month on their phone and, according to a ComScore study from March 2010: 63% of Americans are using text messaging. The use of SMS or text alerts as patient reminders has been shown to reduce the ‘noshow’ rate by 73% (or 1,837 fewer ‘lost’ visits) according to a recent study for Kaiser Permanente by mobilStorm. Kaiser was able to contain their communication infrastructure costs, while saving $150 per appointment (their no-show cost) which equaled a total cost savings of more than $275,000 at just a single clinic.

Ideally, SMS text and/or email alerts should be integrated into a clinic’s scheduling system; automatically alerting patients to upcoming appointments or schedule changes. And why stop there? The potential impact of these alerts could extend to reminding patients to complete their home exercise programs, or give therapists updates on symptomatic responses to new treatment regimens.

A study conducted by comScore found that daily use of Smartphones to access emails rose by 40 percent in the last quarter of 2010. Laptops and desktops it seems, have become primitive mediums for real-time communication. As our patients become more and more tech-savvy, they will begin to expect these type of mobile conveniences from their service providers. In addition to the considerable cost-saving benefits, automated communication can also serve to improve patient/therapist interaction, increase patient participation in their rehabilitation regimen and thereby improve patient outcomes. Have you considered integrating automated SMS text or email alerts into your clinic?

Bronwyn Spira, PT, and Tejal Ramaiya, DPT, CSCS authored this guest post. They can be found at www.forcetherapeutics.com, www.facebook.com/forcetherapeutics, or www.twitter.com/ForceTherEx.

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Smart Phone Use by Physical Therapists

A Physical Therapist using his cell phone today in clinic.

Houston, we have a problem!

Kyle’s post about smart phone use by physicians had a brief reference to some data attempting to describe smart phone use by PT’s. Well, we did some digging and discovered the real figures. This information is preliminary data obtained when PT Journal surveyed a representative sample of APTA member subscribers and was relayed to me by personal communication from the managing editor. The response rate was limited (~30%) which is why this is preliminary data, but I’m told the demographics of the responders matched the journal’s overall demographics. The numbers are concerning when the respondents were asked, “Do you use a smartphones to access professional content?”

Essentially, more than half (54%) of the respondents from this preliminary survey were not interested in using smart phones to access professional content, thus rendering the phones significantly less smart. We have no idea how many PT’s own smart phones, but to me it this question is more important that how many people own a smart phone. To compare, numbers for physician use of smart phones range from 72% to 80% depending on the survey. Yikes!

Why the disparity between two related professions? I’m just not sure. I am looking forward to more data of this sort. We need to figure this out. I’ll leave you with this quote from Stewart Brand:

“Once a new technology rolls over you, if you’re not part of the steamroller, you’re part of the road”

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Say Hello to Mike Pascoe

As you may have seen from his first post, our second new author is full of energy and really likes sharing! That’s a good combo for this blog. Mike and I have been acquaintances for several years now, albeit in a completely virtual sense. That is, until earlier this year when he took me on a tour of Boulder, CO. We found a coffee shop that could make this and had some real geeky conversation:

Mike is also just beginning a new phase of his career. He’s signed on to a faculty position at the Univeristy of CO, and is instructing Anatomy in the Physical Therapy program. He’ll be attending his first CSM conference this week, so if you see a tall fellow live-blogging and tweeting, run up and welcome him into the field of physical therapy.

About Mike:

Mike Pascoe, PhD recently joined the faculty of the Physical Therapy Program at the University of Colorado Health Sciences Center as a senior instructor of clinical anatomy. He graduated in December 2010 from the University of Colorado Boulder, where he studied age-associated differences in motor unit activity under the direction of Roger Enoka, PhD. He is married to Stephanie Pascoe PT, DPT, OCS, and together they enjoy traveling, snow boarding, and discussing basic research and clinical practice over cups of coffee.

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Best of Tech 2010…PT Edition

Hello.

If you read as many blogs as I do (see Google Reader later in this post) you probably noticed many of them put together an end of the year review of what tools made a big impact throughout the year. I thought it would be a good exercise for physical therapists to see what devices/services exist out there and to consider the benefits of integrating them into your workflow. Maybe they can help you in 2011?

Let’s get started.

1. iPad

iPad was unveiled by Steve Jobs on January 27, 2010. Since then, it has become the most popular tablet device on the market and hundreds of applications are developed every month for use on the device, many that can be useful in a physical therapy clinic. In place of discussing iPad in the PT clinic in this post, I refer you to a post on this very blog, from Dec 20, 2010.

It will be interesting to see what happens with the iPad with the much anticipated release of the 2nd generation, rumored to occur Feb/Mar of 2011. Perhaps we’ll even see some sweet demos a “technopalooza” at the Combined Sections Meeting this month week.

2. The “Cloud”

I’m not talking about cumulonimbus here. I’m referring to the storage of information on a remote server, thereby making it accessible across many devices and to many users. It seems that the days of storing data on hard drives within your device are numbered – AWESOME COMMON CRAFT VIDEO HERE. Some cloud-based services that really gained traction in 2010 include Dropbox, Springpad, Google Docs, and Google Reader. Mike Reinold has an excellent post over on his blog about the applicability of these services in a professional setting.

Dropbox came in handy this past month at Colorado Manipalooza (Jan 22), when the instructor Paul Mintken shared with us all of the videos demonstrating the manipultion techniques that were covered. Although I cannot perform these techniques myself, I can imagine a clinician pulling out their smart phone (they all have one right?) launching the dropbox app, and reviewing a technique prior to meeting with a patient.

An area ripe for the enhancements of cloud-based service is the management of Electronic Medical Records (EMR). Bronwyn and Tejal have covered this in detail in a post on My Physcial Therapy Space.

So, you think you are already “in the cloud”? Take the nifty quiz put together by who else, Google.

3. Google

I say it all the time, everything Google touches turns to gold. My professional and personal endeavors have been made much easier by leveraging all the tools Google has to offer. Here’s a short list of reasons why you need to get a Google account, right now:

  • Gmail – have a pesky email quota on your work/school account? Forward your email to Gmail, archive all your messages and never worry about that quota 95% warning again
  • Google Docs – working on an in-service presentation with co-workers? Collaborate on a shared document to combine your efforts.
  • Google Reader – staying current with PT research. I get so many questions about Google Reader that I actually put together a screencast to show off how effective this tool can be. I consistently find out about the best research either weeks ahead of my peers do or I get notified on articles published on topics in Journals they might not have on their radar screen. Have a look at the screencast here:

  • Gcal – a really handy way to edit your schedule on a variety of computers and from your smart phone.

4. Video

If a picture is worth a thousand words, than a video is worth…..more. It’s getting easier to produce good quality videos with portable HD camcorders apps like iMovie and it’s gotten way easier to share those videos on the web with platforms like YouTube and vimeo. There have been so many good examples of the use of video in physical therapy in 2010.

For the 3rd year, Evidence in Motion put on their Elevator Pitch Contest. This contest required entrants to convey the selected message in a 30 second video. Maybe if you’re on the faculty of a PT Program you could encourage your students to participate in 2011. After all, the more competition, the better the videos will become. You can view the Second, and Third Place videos here. First place video here:

Although not a new technology, we’ve seen the embedding of lecture video become more common place in PT. This makes the presenters message reach more ears than just those in the lecture hall. Like this popular lecture from Dr. Timothy Flynn.

Lastly, to lighten to mood, we saw a series of videos from the students at Pacific University taking popular songs and giving them a PT twist:

5. Social Media

I’m not that compelled to review all the hundreds of social networks out there, those posts are a dime a dozen. And a lot of the biggest networks have been around prior to 2010. What I would like to emphasize is how these tools can be used to network, using the upcoming Combined Sections Meeting as an example:

  • Twitter – this tool is all about what is happening here and now. Check out the hashtag #CSM2011 to see what people are saying about the meeting. I was able to “participate” in conversations happening at #CSM2010 even though I could not be there in person. Also keep track of people attending #CSM2011 by following this curated list of twitter accounts attending the meeting (let me know if you want to be added to the list).
  • Plancast – another way to share your plans to attend certain events, like the meeting as a whole, or even any specific events at the meeting.
  • LinkedIn – meet someone neat at #CSM2011? Connect with them after the meeting using LinkedIn.

I you were expecting something to be on this list and it wasn’t there, please let me know in the comments below (that’s a big part of social media).

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Meet Kyle Ridgeway

This month, PT Think Tank is welcoming new authors! Fresh from some heroic writings on the AAOMPT Student SIG blog, Kyle Ridgeway is on board. Kyle currently manages the AAOMPT social media streams and is an avid hat wearer. Check out his first post about smart phone usage. Here’s a bit about him:

Kyle Ridgeway


Kyle is from Mukilteo (north of Seattle), WA. He completed his Bachelors of Arts degree in neuroscience in 2007 at Pomona College in Claremont, CA where he also competed in varsity football. After numerous injuries, including 2 knee surgeries Kyle solidified his commitment to becoming a physical therapist. In 2010, he received his Doctor of Physical Therapy (DPT) degree from University of Colorado Denver.

Dr. Ridgeway has broad clinical interests and experiences ranging from outpatient pulmonary rehabilitation to injury prevention and sports performance. He currently practices at private outpatient clinic, University of Colorado Hospital (UCH) as well as a long term acute care hospital. At UCH he is aiding in research, and treating within the confines of a randomized control trial, pertaining to early physical therapy with patients who are critically ill in the intensive care unit and require mechanical ventilation.

He is very interested in leveraging technology and social media in patient care, education, research, and advocacy. Dr. Ridgeway is excited by novel practice settings and practice models for physical therapists as the profession continues to evolve.

Dr. Ridgeway is an active member of the American Physical Therapy Association (APTA) and the American Academy of Orthopedic Manual Physical Therapists (AAOMPT). He enjoys playing golf whether it be outdoors or indoors through a skytrak golf simulator, skiing, downhill mountain biking, and various other outdoor and athletic adventures.

Connect with Kyle here: